7. Diseases Of The Gallbladder And Bile Ducts

Question 1

Chemical that stimulates gallbladder contraction.

Answer 1

CCK

Question 2

This chemical mediates the relaxation of the sphincter of Oddi.

Answer 2

CCK

Question 3

What does relaxation of the sphincter of Oddi allow?

Answer 3

Biliary and pancreatic secretions to enter the duodenum.

Question 4

Composition of micelles of bile salts.

Answer 4

Cholesterol

Phospholipids

Question 5

Main component of bile pigments

Answer 5

Bilirubin

Question 6

Type of gallstone that is mostly calcium bilirubinate (black and brown).

Answer 6

Pigment (associated w/chronic infection or disease states w/ chronic hemolysis)

Question 7

________secrete bile acids.

Answer 7

Hepatocytes

Question 8

The 5 F’s: Risk factors for Cholelithisasis

Answer 8

Fat (BMI >30)
Female
Fertile
Forty >40
Fair
*Familial

Question 9

Composition of biliary sludge

Answer 9

Cholesterol crystals
Calcium bilirubinate
Mucin gels

Question 10

Presence of sludge means: (two things)

Answer 10

1) normal balance deranged

2) Nucleation

Question 11

Stone and sludge in the gallbladder can cause these 3 main issues: (there are more)

Answer 11

1) Cholelithiasis-stones present, no sx
2) Acute cholecystitis- inflammation
3) Chronic cholecystitis-“great imitator”

Question 12

This produces increased intraluminal pressure and distension of the gallbladder viscous that CANNOT be relieved by repeated biliary contractions.

Answer 12

Obstruction of the cystic duct OR CBD by stone

Question 13

A patient presents with SEVERE pain in RUQ that radiates to right shoulder. Consider:

Answer 13

Biliary colic

Question 14

Big factor that should make you suspicious of acute cholecystitis?

Answer 14

Long duration of pain (>5 hrs)

Question 15

Precipitating factors for biliary colic:

Answer 15

Fatty meal
Meal after fasting
Any meals

Question 16

When does biliary colic usually occur?

Answer 16

Nocturnal, w/in a few hrs of retiring

Question 17

Arrest of inspiration on palpation of gallbladder.

Answer 17

Murphy’s sign

Question 18

First step in evaluation for gallbladder disease.

Answer 18

Ultrasound

Question 19

If ultrasound of gallbladder is inconclusive and patient is NOT acutely ill, what would be your next step?

Answer 19

HIDA scan

• fast 4 hrs prior
• evaluated bile-excreting function of liver and gallbladder EF

Question 20

If pt. is acutely ill with gallstones, what else would you test for?

Answer 20

CBC (leukocytosis?)

Hepatic panel

Question 21

_________% of people with asymptomatic gallstones will remain asymptomatic-25yrs.

Answer 21

60-80

Question 22

Gallbladder polyps occur in _____% of pop.

Answer 22

5

Question 23

A patient comes in for an ultrasound (not gallbladder related) and you find an 11mm polyp. She is 59 yrs old. What should you do?

Answer 23

Cholestystectomy

Question 24

A 49 yr old patient comes in for a routine RUQ ultrasound (not sure what for), she has no pain, fever etc. You find a 9mm polyp. What should you do?

Answer 24

Monitor

Question 25

A patient comes with SUDDEN RUQ pain, 101 fever, and leukocytosis. Consider:

Answer 25

Acute cholecystitis

Question 26

3 sources of inflammation of the gallbladder wall in acute cholecystitis.

Answer 26

1) Mechanical inflammation (distention) 2) Chemical inflammation (local tissue factors) 3) Bacterial inflammation (E. Coli, Strep etc)

Question 27

Acute inflammation of the gallbladder wall following obstruction of the cystic duct by a stone.

Answer 27

Acute cholecystitis

Question 28

Steps for acute cholecystitis work up.

Answer 28

1) Ultrasound! 2) Hepatic panel 3) CBC *gen. Surg

Question 29

A pt. Comes in with no current pain, but said they recently had a “EXTREME bout of pain in the RUQ” a few days ago in the middle of the night. Next steps?

Answer 29

Ultrasound>Gen Surgery *tell them to go to ER next time this happens

Question 30

What kind of drugs can induce sphincter of Oddi spasms?

Answer 30

Morphine-based

Question 31

If a patient with acute cholecystitis is in severe pain, high fever and leukocytes, what would you do?

Answer 31

1) Medically stabilize. * NPO, IV FLUIDS, Fix electrolytes, NSAIDS, IV Antibiotics 2) Lap Cholecystitis

Question 32

Alternative to lap chol for extremely ill pt’s.

Answer 32

Percutaneous cholecystostomy tube (* gen surg decides)

Question 33

What would you use to evaluate for common bile duct stones during a lap chol?

Answer 33

Intraoperative cholangiogram (IOC)

Question 34

During a lap chol, what would you use to retrieve small CBD stones?

Answer 34

ERCP

Question 35

A post-cholecystectomy complains of severe diarrhea, what could give them?

Answer 35

Bile acid sequestration like Cholestyramine (Questran)

Question 36

A patient presents with severe abdominal pain, jaundice, and a high fever with chills. What is this triad of sx's called and what might be happening?

Answer 36

Charcot’s triad Bile Duct Leak

Question 37

How would you evaluate a build duct leak?

Answer 37

ERCP *Stent CBD

Question 38

When gallstones pass into the CBD:

Answer 38

Choledocholithiasis

Question 39

When bile ducts are partially to completely obstructed and bacteria begins to climb the biliary tree into the liver:

Answer 39

CHOLANGITIS

Question 40

Type of cholangitis in which pus is under pressure in a completely obstructed ductal system.

Answer 40

Suppurative cholangitis | *Mortality rate approaches 100%

Question 41

Tx for cholangitis

Answer 41

``` Empiric antibiotics (IV) ERCP or surgical drainage ```

Question 42

What drug would you use to dissolve cholesterol type stones?

Answer 42

Ursodeoxycholic acid (UCDA)